Employment Medical Questionnaire

Employment medical questionnaires are those types of questionnaire which are framed or drafted by companies so that they can get information about the medical history of their prospective employees. These questionnaires are used by the companies to know the accurate and honest medical history or condition of applicants.

One must honestly answer the questions given in such questionnaires as the information is generally kept confidential. Given below is a sample of an employment medical questionnaire which can be used by any person for the purpose of reference.

Sample Employment Medical Questionnaire

Name of applicant:

Age of applicant:

Date of birth of applicant:

Gender of applicant

Contact number of applicant

Address of applicant:

Email address:

The following are a few employment medical questions which must be answer accurately and honestly. The answers given by you shall be kept confidential.

Q1. Do you smoke?

a) Yes, regularly

b) Yes, occasionally

c) No

Q2. Do you drink?

a) Yes, regularly

b) Yes, occasionally

c) No

Q3. Are you suffering from any kind of heart related problem?

a) Yes

b) No

Q4. Are you suffering from any kind of liver or lung condition or problem?

a) Yes

b) No

Q5. Have you had any medical condition in the past?

a) Yes

b) No

Q6. If the answer to the previous question is yes, then please explain the details of the condition you suffered from.

________________________________________________________

Q7. Are you under any kind of medication?

a) Yes

b) No

Q8. Do you suffer from any skin problem?

a) Yes

b) No

Q9. Have you suffered from any medical condition which has caused you to miss work?

a) Yes

b) No

Q10. Have you ever been admitted to a hospital?

a) Yes

b) No

Q11. Do you wear specs?

a) Yes

b) No

Q12. If yes, then please specify the details of your power of eyesight.